Provider Demographics
NPI:1730343013
Name:DAVIS, KENNETH HOUSTON (DMD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:HOUSTON
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:AZ
Mailing Address - Zip Code:85939-1550
Mailing Address - Country:US
Mailing Address - Phone:928-457-0758
Mailing Address - Fax:
Practice Address - Street 1:606 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:AZ
Practice Address - Zip Code:85939
Practice Address - Country:US
Practice Address - Phone:928-457-0758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD7589122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist